Publications by authors named "Minal Patel"

253 Publications

A Comprehensive Qualitative Review of Studies Evaluating the Impact of Local US Laws Restricting the Sale of Flavored and Menthol Tobacco Products.

Nicotine Tob Res 2021 Sep 15. Epub 2021 Sep 15.

Truth Initiative Schroeder Institute, Washington, DC USA.

Objectives: To assess the quality of evidence on the effectiveness of local US laws restricting the sale of flavored tobacco products.

Methods: We conducted a systematic search and qualitative scoping review of English-language papers published through May 2020 that evaluated flavored tobacco sales policies implemented by US jurisdictions during 2010-2019. We constructed a conceptual model for flavored and menthol tobacco sales restriction outcomes, assigned GRADE quality of evidence ratings to policy outcomes evaluated through the included studies, and summarized factors that might explain weak or inconsistent findings.

Results: We found moderate to high quality of evidence associating policy implementation with reduced availability, marketing, and sales of policy-restricted products, and decreased youth and adult tobacco use of these products; however, policy exclusions and exemptions, implementation challenges, tobacco industry actions (e.g., marketing of concept-named flavored products; exploiting policy exemptions for certain store types), and consumer responses (e.g., cross-border or illicit purchasing) might undermine or mitigate intended policy effects.

Conclusions: Flavored and menthol tobacco product sales restrictions implemented and evaluated in US jurisdictions appear to have achieved some of their intended outcomes; however, deficiencies in study designs, methods, and metrics could contribute to equivocal findings on quality of evidence associating policy implementation and outcomes. Gaps in the evidence are beginning to be filled with research using more rigorous study designs, improved measurement and analytic methods, and longer-term follow-up.

Implications: In the absence of comprehensive federal action, US jurisdictions have the obligation to restrict flavored and menthol product sales to protect vulnerable populations from tobacco-related harms. The considerable expenditure of financial resources, political will, and time dedicated to policy adoption and implementation argue for evaluation studies designed to maximize the quality of evidence. This review offers generalizable insights into evaluation findings that can inform efforts to enhance tobacco control policy implementation and impact in the US and globally.
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http://dx.doi.org/10.1093/ntr/ntab188DOI Listing
September 2021

Cells of the human intestinal tract mapped across space and time.

Nature 2021 09 8;597(7875):250-255. Epub 2021 Sep 8.

European Molecular Biology Laboratory, European Bioinformatics Institute, Wellcome Genome Campus, Cambridge, UK.

The cellular landscape of the human intestinal tract is dynamic throughout life, developing in utero and changing in response to functional requirements and environmental exposures. Here, to comprehensively map cell lineages, we use single-cell RNA sequencing and antigen receptor analysis of almost half a million cells from up to 5 anatomical regions in the developing and up to 11 distinct anatomical regions in the healthy paediatric and adult human gut. This reveals the existence of transcriptionally distinct BEST4 epithelial cells throughout the human intestinal tract. Furthermore, we implicate IgG sensing as a function of intestinal tuft cells. We describe neural cell populations in the developing enteric nervous system, and predict cell-type-specific expression of genes associated with Hirschsprung's disease. Finally, using a systems approach, we identify key cell players that drive the formation of secondary lymphoid tissue in early human development. We show that these programs are adopted in inflammatory bowel disease to recruit and retain immune cells at the site of inflammation. This catalogue of intestinal cells will provide new insights into cellular programs in development, homeostasis and disease.
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http://dx.doi.org/10.1038/s41586-021-03852-1DOI Listing
September 2021

Image Processing for Public Health Surveillance of Tobacco Point-of-Sale Advertising: Machine Learning-Based Methodology.

J Med Internet Res 2021 Aug 27;23(8):e24408. Epub 2021 Aug 27.

Truth Initiative Schroeder Institute, Washington, DC, United States.

Background: With a rapidly evolving tobacco retail environment, it is increasingly necessary to understand the point-of-sale (POS) advertising environment as part of tobacco surveillance and control. Advances in machine learning and image processing suggest the ability for more efficient and nuanced data capture than previously available.

Objective: The study aims to use machine learning algorithms to discover the presence of tobacco advertising in photographs of tobacco POS advertising and their location in the photograph.

Methods: We first collected images of the interiors of tobacco retailers in West Virginia and the District of Columbia during 2016 and 2018. The clearest photographs were selected and used to create a training and test data set. We then used a pretrained image classification network model, Inception V3, to discover the presence of tobacco logos and a unified object detection system, You Only Look Once V3, to identify logo locations.

Results: Our model was successful in identifying the presence of advertising within images, with a classification accuracy of over 75% for 8 of the 42 brands. Discovering the location of logos within a given photograph was more challenging because of the relatively small training data set, resulting in a mean average precision score of 0.72 and an intersection over union score of 0.62.

Conclusions: Our research provides preliminary evidence for a novel methodological approach that tobacco researchers and other public health practitioners can apply in the collection and processing of data for tobacco or other POS surveillance efforts. The resulting surveillance information can inform policy adoption, implementation, and enforcement. Limitations notwithstanding, our analysis shows the promise of using machine learning as part of a suite of tools to understand the tobacco retail environment, make policy recommendations, and design public health interventions at the municipal or other jurisdictional scale.
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http://dx.doi.org/10.2196/24408DOI Listing
August 2021

Cancer risk perception and physician communication behaviors on cervical cancer and colorectal cancer screening.

Elife 2021 08 24;10. Epub 2021 Aug 24.

Outreach and Health Disparities Research, University of Michigan Rogel Cancer Center, Ann Arbor, United States.

Background: Women 50-65 years of age have the lowest cervical and colorectal cancer (CRC) screening rates among ages recommended for screening. The primary aim of this work is to determine how cancer risk perceptions and provider communication behaviors, in addition to known demographic factors, influence the uptake of both cervical and CRC screening or a single screen among women in southeast Michigan.

Methods: Fourteen health services and communication behavior questions were adapted from the Health Information National Trends Survey (HINTS) and administered to a multiethnic sample of adults in southeast Michigan. The outcome variable was self-reported up-to-date cervical cancer and/or CRC screening as defined by the United States Preventive Services Task Force (USPSTF). Demographic and cancer risk/communication behavior responses of the four screening populations (both tests, one test, no tests) were analyzed with multinomial regression for all comparisons.

Results: Of the 394 respondents, 54% were up to date for both cervical and CRC screening, 21% were up to date with only cervical cancer screening and 12% were up to date for only CRC screening. Of the 14 risk perception and communication behavior questions, only 'Did your primary care physician (PCP) involve you in the decisions about your health care as much as you wanted?' was significantly associated with women having both screens compared to only cervical cancer screening (aOR 1.67; 95% CI: 1.08, 2.57). The multivariate model showed age, and Middle East and North African (MENA) ethnicity and Black race, in addition to PCP-patient dyad decision-making to be associated with the cancer screenings women completed.

Conclusions: Optimizing PCP-patient decision-making in health care may increase opportunities for both cervical cancer and CRC screening either in the office or by self-sampling. Understanding the effects of age and the different interventional strategies needed for MENA women compared to Black women will inform future intervention trials aimed to increase both cancer screenings.

Funding: This work was supported by NIH through the Michigan Institute for Clinical and Health Research UL1TR002240 and by NCI through The University of Michigan Rogel Cancer Center P30CA046592-29-S4 grants.
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http://dx.doi.org/10.7554/eLife.70003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8384416PMC
August 2021

Vaccine preventable diseases surveillance in Nepal: How much does it cost?

Vaccine 2021 Aug 18. Epub 2021 Aug 18.

Immunization, Vaccines, and Biologicals, World Health Organization, Avenue Appia 20, 1211 Geneva, Switzerland. Electronic address:

Assessing the cost of vaccine preventable diseases (VPD) surveillance is becoming more important in the context of the Global Polio Eradication Initiative (GPEI) funding transition, since GPEI support to polio surveillance helped the incremental building of VPD surveillance systems in many countries, including low income countries such as Nepal. However, there is limited knowledge on the cost of conducting VPD surveillance, especially the national cost for surveillance of multiple vaccine-preventable diseases. The current study sought to calculate the economic and financial costs of Nepal's comprehensive VPD surveillance systems from July 2016 to July 2017. At thecentral level, all surveillance units were included in the sample. At sub-national level, a purposive sampling strategy was used to select a representative sample from locations involved in conducting surveillance. The sub-national sample costs were extrapolated to the nationwide VPD surveillance system. Nepal's total annual economic cost of VPD surveillance was USD 4.81 million or USD 0.18 per capita, while the total financial cost was USD 4.38 million or USD 0.16 per capita. Government expenditures accounted for 56% of the total economic cost, and World Health Organization accounting for 44%. The biggest cost driver was personnel accounting for 51% of the total economic cost. WHO supported trained surveillance personnel through donor funding, mainly from Global Polio Eradication Initiative. As a polio transition priority country, Nepal will need to make strategic choices to fully self-finance or seek full donor support or a mixed-financing model as polio program funding diminishes.
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http://dx.doi.org/10.1016/j.vaccine.2021.07.038DOI Listing
August 2021

Policy Support for Smoke-Free and E-Cigarette Free Multiunit Housing.

Am J Health Promot 2021 Aug 4:8901171211035210. Epub 2021 Aug 4.

Schroeder Institute at Truth Initiative, Washington, DC, USA.

Purpose: Estimate public support for prohibiting multiunit housing (MUH) e-cigarette and cigarette use.

Design: Cross-sectional study.

Setting: Data from an online panel survey.

Sample: A Fall 2018 nationally representative sample of 3,415 (99.3% response rate) United States (US) adults 18-64 years old.

Measures: Policy support for prohibiting MUH smoking and e-cigarette use, sociodemographics, and tobacco perceptions and behaviors.

Analysis: Weighted multivariate logistic regression examined predictors of support for prohibiting 1) cigarette use and 2) e-cigarette use in MUH.

Results: Most respondents expressed support for prohibiting smoking (76.9%) and e-cigarette use (74.0%) in MUH. About 17% (n = 588) of the sample lived in MUH, and living in MUH was not predictive of support for either policy. For both cigarette and e-cigarette policies, current smokers (n = 630; OR = 0.44, p < 0.001; OR = 0.59, p < 0.01) and current e-cigarette users (n = 305; OR = 0.42, p < 0.001; OR = 0.22, p < 0.001) had lower odds of support. Notably, while most smokers supported prohibiting cigarette (51.4%) and e-cigarette use in MUH (51.1%), there was less support among current e-cigarette users for prohibiting cigarette (48.1%) and e-cigarette use in MUH (34.5%).

Conclusion: Majority support for prohibiting smoking and e-cigarette use in MUH is promising for policy adoption; however, lower support of both policies among e-cigarette users needs to be examined, as increasing use of e-cigarettes may be shifting social norms away from support for smoke free housing policies.
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http://dx.doi.org/10.1177/08901171211035210DOI Listing
August 2021

Evaluation of post-introduction COVID-19 vaccine effectiveness: Summary of interim guidance of the World Health Organization.

Vaccine 2021 07 1;39(30):4013-4024. Epub 2021 Jun 1.

World Health Organization, 20 Avenue Appia, Geneva 1211, Switzerland.

Phase 3 randomized-controlled trials have provided promising results of COVID-19 vaccine efficacy, ranging from 50 to 95% against symptomatic disease as the primary endpoints, resulting in emergency use authorization/listing for several vaccines. However, given the short duration of follow-up during the clinical trials, strict eligibility criteria, emerging variants of concern, and the changing epidemiology of the pandemic, many questions still remain unanswered regarding vaccine performance. Post-introduction vaccine effectiveness evaluations can help us to understand the vaccine's effect on reducing infection and disease when used in real-world conditions. They can also address important questions that were either not studied or were incompletely studied in the trials and that will inform evolving vaccine policy, including assessment of the duration of effectiveness; effectiveness in key subpopulations, such as the very old or immunocompromised; against severe disease and death due to COVID-19; against emerging SARS-CoV-2 variants of concern; and with different vaccination schedules, such as number of doses and varying dosing intervals. WHO convened an expert panel to develop interim best practice guidance for COVID-19 vaccine effectiveness evaluations. We present a summary of the interim guidance, including discussion of different study designs, priority outcomes to evaluate, potential biases, existing surveillance platforms that can be used, and recommendations for reporting results.
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http://dx.doi.org/10.1016/j.vaccine.2021.05.099DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8166525PMC
July 2021

Support for cigarette filter waste policies among US adults.

Tob Control 2021 Jun 8. Epub 2021 Jun 8.

Graduate School of Public Health, San Diego State University, San Diego, California, USA.

Introduction: Little is known on whether cigarette filter-related knowledge or beliefs are associated with support for policies to reduce their environmental impact.

Methods: A cross-sectional, population-based sample of US adults aged 18-64 years (n=2979) was used to evaluate filter-related knowledge and beliefs by smoking status using data collected between 24 October 2018 and 17 December 2018. Multivariate logistic regression models explored whether these knowledge and belief items were associated with support for two policies, a US$0.75 litter fee and a ban on sales of filtered cigarettes, controlling for demographic characteristics and smoking status.

Results: Regardless of smoking status, 71% did not know plastic was a cigarette filter component and 20% believed filters were biodegradable. Overall, 23% believed filters reduce health harms and 60% believed filters make it easier to smoke; 90% believed cigarette butts are harmful to the environment. Individuals believing cigarette butts harmed the environment were more likely to support a litter fee (adjusted OR (aOR)=2.33, 95% CI: 1.71 to 3.17). Individuals believing that filters are not biodegradable had higher odds of supporting a litter fee (OR=1.47, 95% CI: 1.15 to 1.88). Respondents believing that filters do not make cigarettes less harmful were more likely to support a litter fee (aOR=1.50, 95% CI: 1.20 to 1.88) and filter ban (aOR=2.03, 95% CI: 1.64 to 2.50). Belief that filters make it easier to smoke was associated with decreased support for a filter ban (aOR=0.69, 95% CI: 0.58 to 0.83).

Conclusions: Comprehensive efforts are needed to educate the public about the impact of cigarette filters in order to build support for effective tobacco product waste policy.
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http://dx.doi.org/10.1136/tobaccocontrol-2020-056451DOI Listing
June 2021

Predictors of screening for cervical and colorectal cancer in women 50-65 years old in a multi-ethnic population.

Prev Med Rep 2021 Jun 19;22:101375. Epub 2021 Apr 19.

Department of Health Behavior and Health Education, University of Michigan, Ann Arbor, MI, USA.

Middle Eastern/North Africa (MENA) women are often not identified in cancer screening studies. The aim of this study was to determine the rates and predictors of cervical and colorectal cancer (CRC) screening for women 50-65 years of three race/ethnicities. White, black and MENA women of Southeast Michigan were surveyed once in 2019 for demographics, health care barriers, chronic diseases, and cancer screening updates using in-person, telephone, and online methods. Descriptive statistics and multivariate multinomial logistic regression were used to predict up-to-date colorectal cancer and cervical cancer screening. All analyses were adjusted by local population weights for comparability and generalizability. 394 women participated with 54% up-to-date on both screenings, 21% for cervical cancer screening alone, and 12% for CRC alone. Women more likely to be up-to-date for only cervical cancer screening compared to both cancer screens are younger (aOR 0.83 (95% CI 0.76, 0.92), are of MENA descent (7.97 (2.46, 25.76) and have no insurance (9.41 (1.07, 82.92). There are no predictors for women being up-to-date for CRC screening alone compared to both screens. Among women 50-65 years old, being up-to-date in cervical cancer screening is unrelated to being up-to-date for CRC screening. Compared to Healthy People 2020, there are significant gaps in cervical and CRC screening among women 50-65 years old of all races, but particularly among women of MENA descent who are even less likely to have CRC screening than cervical cancer screening.
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http://dx.doi.org/10.1016/j.pmedr.2021.101375DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8086134PMC
June 2021

A Scoping Review of Behavioral Interventions Addressing Medical Financial Hardship.

Popul Health Manag 2021 May 14. Epub 2021 May 14.

Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, Michigan, USA.

Little information has been compiled across studies about existing interventions to mitigate issues of medical financial hardship, despite growing interest in health care delivery. The purpose of this qualitative systematic scoping review was to examine content and outcomes of interventions to address medical financial hardship. PRISMA guidelines were applied to present results using PubMed, Scopus, and CINAHL, published between January 1980 and August 2020. Additional studies were identified through reference lists of selected papers. Included studies focused on mitigating medical financial hardship from out-of-pocket (OOP) health care expenses as an intervention strategy with at least 1 evaluation component. Screening 2412 articles identified 339 articles for full-text review, 12 of which met inclusion criteria. Variation was found regarding targets and outcome measurement of intervention. Primary outcomes were in the following categories: financial outcomes (eg, OOP expenses), behavioral outcomes, psychosocial, health care utilization, and health status. No included studies reported significant reduction in OOP expenses, perceptions of financial burden/toxicity, or health status. However, changes were observed for behavioral outcomes (adherence to treatment, patient needs addressed), some psychosocial outcomes (mental health symptoms, perceived support, patient satisfaction), and care utilization such as routine health care. No patterns were observed in the achievement of outcomes across studies based on intensity of intervention. Few rigorous studies exist in this emerging field, and studies have not shown consistent positive effects. Future research should focus on conceptual clarity of the intervention, align outcome measurement and achieve consensus around outcomes, and employ rigorous study designs, measurement, and outcome follow-up.
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http://dx.doi.org/10.1089/pop.2021.0043DOI Listing
May 2021

The Association of Unfairness with Mental and Physical Health in a Multiethnic Sample of Adults: Cross-sectional Study.

JMIR Public Health Surveill 2021 May 10;7(5):e26622. Epub 2021 May 10.

Arab Community Center for Economic and Social Services, Dearborn, MI, United States.

Background: Two psychosocial constructs that have shown consistent associations with negative health outcomes are discrimination and perceived unfairness.

Objective: The current analyses report the effects of discrimination and unfairness on medical, psychological, and behavioral outcomes from a recent cross-sectional survey conducted in a multiethnic sample of adults in Michigan.

Methods: A cross-section survey was collected using multiple approaches: community settings, telephone-listed sample, and online panel. Unfairness was assessed with a single-item previously used in the Whitehall study, and everyday discrimination was assessed with the Williams 9-item scale. Outcomes included mental health symptoms, past-month cigarette use, past-month alcohol use, past-month marijuana use, lifetime pain medication use, and self-reported medical history.

Results: A total of 2238 usable surveys were collected. In bivariate analyses, higher unfairness values were significantly associated with lower educational attainment, lower age, lower household income, and being unmarried. The highest unfairness values were observed for African American and multiracial respondents followed by Middle Eastern or North African participants. Unfairness was significantly related to worse mental health functioning, net adjustment for sociodemographic variables, and everyday discrimination. Unfairness was also related to self-reported history of depression and high blood pressure although, after including everyday discrimination in the model, only the association with depression remained significant. Unfairness was significantly related to 30-day marijuana use, 30-day cigarette use, and lifetime opiate use.

Conclusions: Our findings of a generally harmful effect of perceived unfairness on health are consistent with prior studies. Perceived unfairness may be one of the psychological pathways through which discrimination negatively impacts health. Future studies examining the relationships we observed using longitudinal data and including more objective measures of behavior and health status are needed to confirm and extend our findings.
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http://dx.doi.org/10.2196/26622DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8145085PMC
May 2021

Oral nicotine marketing claims in direct-mail advertising.

Tob Control 2021 May 6. Epub 2021 May 6.

Behavioral Sciences, University of Kentucky College of Medicine, Lexington, KY, USA.

Background: Little is known regarding how oral nicotine products (eg, nicotine pouches, lozenges) are marketed to consumers, including whether potential implicit reduced harm claims are used. In the current study, we explored the marketing claims present in a sample of direct-mail oral nicotine advertisements sent to US consumers (March 2018-August 2020).

Methods: Direct-mail ads (n=50) were acquired from Mintel and dual-coded for the following claims: alternative to other tobacco products, ability to use anywhere, spit-free, smoke-free and product does not contain tobacco leaf. We merged the coded data with Mintel's volume estimate (number of mail pieces sent to consumers) and calculated the proportion of oral nicotine advertisements containing claims by category.

Results: Of the 38 million pieces of oral nicotine direct-mail sent to US consumers, most featured claims that the product could be used anywhere (84%, 31.8 million pieces); was an alternative to other tobacco products (69%, 26.1 million pieces); and did not contain tobacco leaf (eg, 'tobacco leaf-free', 'simple' approach of extracting nicotine from tobacco; 55%, 20.7 million pieces). A slightly smaller proportion contained claims that oral nicotine was 'spit-free' (52%, 19.8 million pieces) or 'smoke-free' (31%, 11.7 million pieces).

Conclusion: Our results provide an early indication of marketing claims used to promote oral nicotine. The strategies documented, particularly the use of language to highlight oral nicotine is tobacco-free, may covey these products as lower-risk to consumers despite the lack of evidence or proper federal authorisation that oral nicotine products are a . Future research is needed to examine consumer perceptions of such claims.
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http://dx.doi.org/10.1136/tobaccocontrol-2020-056446DOI Listing
May 2021

E-Cigarette Use Among Youths and Young Adults During the COVID-19 Pandemic: United States, 2020.

Am J Public Health 2021 06 15;111(6):1132-1140. Epub 2021 Apr 15.

All authors are with the Schroeder Institute at Truth Initiative, Washington, DC.

To determine whether the COVID-19 pandemic affected e-cigarette use among young people in the United States. Data came from a weekly cross-sectional online survey of youths and young adults (aged 15-24 years). Logistic regression analyses measured odds of past-30-day e-cigarette use (n = 5752) following widespread stay-at-home directives (March 14-June 29, 2020), compared with the pre‒COVID-19 period (January 1-March 13, 2020). Logistic regression among a subsample of current e-cigarette users (n = 779) examined factors associated with reduced use following stay-at-home orders. Odds of current e-cigarette use were significantly lower during the COVID-19 pandemic compared with the pre‒COVID-19 period among youths aged 15 to 17 years (odds ratio [OR] = 0.72; 95% confidence interval [CI] = 0.54, 0.96) and young adults aged 18 to 20 years (OR = 0.65; 95% CI = 0.52, 0.81). E-cigarette users with reduced access to retail environments had higher odds of reporting reduced e-cigarette use (OR = 1.51; 95% CI = 1.07, 2.14). COVID-19 stay-at-home directives present barriers to e-cigarette access and are associated with a decline in e-cigarette use among young people. Findings support the urgent implementation of interventions that reduce underage access to e-cigarettes to accelerate a downward trajectory of youth and young adult e-cigarette use.
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http://dx.doi.org/10.2105/AJPH.2021.306210DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8101576PMC
June 2021

Awareness and Preferences for Health Care Chaplaincy Services Among US Adults.

J Am Board Fam Med 2021 Mar-Apr;34(2):368-374

From the Department of Health Behavior & Health Education, University of Michigan, Ann Arbor.

Purpose: Health care chaplains intervene on unmet religious/spiritual (R/S) needs in health care settings that are associated with poor outcomes. Little is known about demand for their services. The purpose of this study was to describe population-level awareness and perceptions of health care chaplains and preferences for their services.

Methods: Data came from a cross-sectional survey of a nationally representative sample of US adults ≥ 18 years of age (n = 1020). Participants were asked about preferences for chaplain services, previous experience and awareness of chaplains, and level of importance on having R/S needs and sources of meaning addressed.

Results: Mean age of the sample was 47.6. Although the majority were aware of chaplains (85%), only 15% indicated they had previous experience with one. Adults who were unaware were younger (38 vs 49 years, < .001), male ( = .007), non-white race/ethnicity ( < .001), and had lower educational attainment ( = .01). Seventy percent reported an interest in having R/S or existential needs met in the context of health care.

Conclusions: The majority of the US population say they are aware of chaplains and desire their services, yet few report previous experience with them in health care. More behavioral interventions are needed to better connect patients to chaplains.
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http://dx.doi.org/10.3122/jabfm.2021.02.200396DOI Listing
September 2021

Beneficiaries' perspectives on improved oral health and its mediators after Medicaid expansion in Michigan: a mixed methods study.

J Public Health Dent 2021 Mar 22. Epub 2021 Mar 22.

University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA.

Objective: To investigate self-reported improved oral health and its mediators, and job-related outcomes, of Medicaid expansion beneficiaries in Michigan.

Methods: This cross-sectional mixed-methods study of adult "Healthy Michigan Plan" (HMP) Medicaid expansion beneficiaries included qualitative interviews with a convenience sample of 67 beneficiaries enrolled for ≥6 months, a stratified random sample survey of 4,090 beneficiaries enrolled for ≥12 months; and Medicaid claims data. We examined unadjusted associations between demographic variables and awareness of dental coverage, self-reported dental care access, dental visits, and self-reported oral health; and between improved oral health and job seeking and job performance. Multivariate analysis examined factors associated with self-reported oral health improvement, adjusting for sociodemographic characteristics, prior health insurance, and having at least one dental visit claim.

Results: Among surveyed beneficiaries, 60 percent received ≥1 dental visit and 40 percent reported improved oral health. Adjusted odds ratios (aOR) for improved oral health were higher for African-American beneficiaries [aOR = 1.61; confidence interval (CI) = 1.28-2.03] and those previously uninsured for ≥12 months (aOR = 1.96; CI = 1.58-2.43). Beneficiaries reporting improved oral health were more likely to report improved job seeking (59.9 percent vs 51 percent; P = 0.04) and job performance (76.1 percent vs 65.0 percent; P < 0.001) due to HMP. Interviewees described previously unmet oral health needs, and treatments that improved oral health, functioning, appearance, confidence, and employability.

Conclusion: Michigan's Medicaid expansion contributed to self-reported improved oral health, which was associated with improved job outcomes. Policymakers should consider the importance of Medicaid dental coverage in reducing oral health disparities and improving the health and socioeconomic well-being of low-income adults and communities when considering this optional benefit.
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http://dx.doi.org/10.1111/jphd.12447DOI Listing
March 2021

Variation in fracture risk estimation among East Asian women.

Am J Manag Care 2021 03 1;27(3):e97-e100. Epub 2021 Mar 1.

Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612. Email:

Objectives: Bone mineral density (BMD) testing and fracture risk calculation help clinicians assess fracture risk and counsel patients. However, predicted fracture risks and outcomes for US East Asian individuals remain understudied.

Study Design: Retrospective cohort study.

Methods: Using standardized clinical profiles for East Asian women aged 70 years, fracture probabilities were estimated using the US Fracture Risk Assessment Tool (FRAX) version 4.1 and corresponding FRAX tools for East Asian countries. Next, clinical and BMD data from 3785 US Asian women aged 65 to 74 years were used to estimate 10-year hip fracture risk (US-Asian FRAX-v3.1) in comparison with actual observed 10-year hip fracture risk (Kaplan-Meier product limit estimate).

Results: For the same patient profile entered in the US-Asian FRAX and country-specific FRAX, the calculated 10-year hip fracture probability varied. Compared with the US-Asian FRAX calculator, the estimate was 2-fold higher using the Taiwan FRAX and Hong Kong FRAX, somewhat higher using the South Korea FRAX and Japan FRAX, and similar using the China FRAX. Among 3785 US Asian women (mean [SD] age, 69 [3] years), 23 experienced a hip fracture during a median follow-up of 6.8 years. Their observed 10-year hip fracture risk was 1.5% (95% CI, 0.8%-2.7%), and their median (interquartile range) predicted fracture probability (US-Asian FRAX-v3.1) was 1.1% (0.6%-2.0%).

Conclusions: Country-specific FRAX estimates varied between the United States and East Asian countries. For US Asian women, the US FRAX-predicted hip fracture probabilities were in the lower range of observed risk. Although these findings support the use of the US-Asian FRAX for hip fracture risk assessment in US East Asian women, further studies are needed, including the examination of Asian subgroups.
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http://dx.doi.org/10.37765/ajmc.2021.88604DOI Listing
March 2021

A Snapshot of Social Risk Factors and Associations with Health Outcomes in a Community Sample of Middle Eastern and North African (MENA) People in the U.S.

J Immigr Minor Health 2021 Mar 11. Epub 2021 Mar 11.

Department of Health Behavior & Health Education, University of Michigan, Ann Arbor, MI, USA.

Social factors (e.g. housing, food security, etc.) contribute significantly to health. The purpose of this study is to describe social risk and social exclusion factors in one of the largest Middle Eastern and North African (MENA) populations in the U.S. and their association with health outcomes. We conducted a cross-sectional study with a community convenience sample of 412 adults who self-identify as MENA. Weighted, adjusted linear regression models were used to examine relationships of interest. Prevalent social risks included transportation barriers to healthcare (33%), food insecurity (33%), and financial strain (25%). In adjusted models, perception of being treated unfairly (Estimate (SE) 0.08 (0.04), p < 0.05) and fear of deportation (0.26 (0.06), p < 0.001) were associated with more social risk factors. More social risk factors were associated with worse self-reported health (0.09 (0.03), p < 0.01), more chronic conditions (0.11 (0.03), p < 0.004), and more mental health symptoms (0.34 (0.14) p < 0.01).Social risk is high among those perceiving unfairness and fear deportation. Those with more social risk factors reported worse health. These findings have implications for social needs screening and referral models that can best serve U.S. MENA sub-populations.
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http://dx.doi.org/10.1007/s10903-021-01176-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7948165PMC
March 2021

Population-scale single-cell RNA-seq profiling across dopaminergic neuron differentiation.

Nat Genet 2021 03 4;53(3):304-312. Epub 2021 Mar 4.

Wellcome Sanger Institute, Wellcome Genome Campus, Hinxton, Cambridge, UK.

Studying the function of common genetic variants in primary human tissues and during development is challenging. To address this, we use an efficient multiplexing strategy to differentiate 215 human induced pluripotent stem cell (iPSC) lines toward a midbrain neural fate, including dopaminergic neurons, and use single-cell RNA sequencing (scRNA-seq) to profile over 1 million cells across three differentiation time points. The proportion of neurons produced by each cell line is highly reproducible and is predictable by robust molecular markers expressed in pluripotent cells. Expression quantitative trait loci (eQTL) were characterized at different stages of neuronal development and in response to rotenone-induced oxidative stress. Of these, 1,284 eQTL colocalize with known neurological trait risk loci, and 46% are not found in the Genotype-Tissue Expression (GTEx) catalog. Our study illustrates how coupling scRNA-seq with long-term iPSC differentiation enables mechanistic studies of human trait-associated genetic variants in otherwise inaccessible cell states.
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http://dx.doi.org/10.1038/s41588-021-00801-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7610897PMC
March 2021

Vaccines work: a reason for celebration and renewed commitment.

Lancet 2021 01;397(10272):351-353

MM Global Health Consulting, Geneva, Switzerland.

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http://dx.doi.org/10.1016/S0140-6736(21)00025-8DOI Listing
January 2021

Quitting e-cigarettes: Quit attempts and quit intentions among youth and young adults.

Prev Med Rep 2021 Mar 5;21:101287. Epub 2021 Jan 5.

Truth Initiative Schroeder Institute, 900 G St NW Fourth Floor, Washington, DC 20001, United States.

While youth and young adult e-cigarette use has risen in the U.S., few studies have explored e-cigarette cessation behavior. This study estimates quit attempts and intentions among young people (aged 15-36) since the rise of high-nicotine products, and examines factors associated with e-cigarette quit attempts and intentions. Current e-cigarette users (past 30-day use, not already quit) were drawn from a national probability-based cohort sample. Data were collected from September to December 2019 (n = 1158). Weighted proportions of past-year quit attempts, intentions to quit in next 30 days, and general intentions to quit (at some point) were calculated. Models estimated cessation outcomes with respect to harm perceptions, friend use, dependence, use frequency, combustible use and demographic factors. Among current e-cigarette users, 54.2% reported general intentions to quit, 15.3% reported intention to quit within 30 days, and 33.3% reported a past-year quit attempt. Past-year quit attempts were associated with higher levels of harm perceptions (adjusted odds ratio (aOR) = 2.08, 95% confidence interval (CI): 1.49-2.92), dependence (aOR = 1.92, 95% CI: 1.44-2.56) and daily use (28 + days) compared to infrequent use (1-5 days) (aOR = 0.23, 95% CI: 0.12-0.43). General intentions to quit were positively associated with harm perceptions (aOR = 1.77, 95% CI: 1.23-2.56) and dependence (aOR = 1.89, 95% CI: 1.41-2.52), and negatively associated with daily use compared to infrequent use (aOR = 0.35, 95% CI: 0.19-0.65). Findings indicate that over half of young e-cigarette users want to quit, highlighting a critical need for policies and resources to promote and sustain e-cigarette cessation among young people.
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http://dx.doi.org/10.1016/j.pmedr.2020.101287DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7808959PMC
March 2021

Interplay between chromosomal alterations and gene mutations shapes the evolutionary trajectory of clonal hematopoiesis.

Nat Commun 2021 01 12;12(1):338. Epub 2021 Jan 12.

Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA.

Stably acquired mutations in hematopoietic cells represent substrates of selection that may lead to clonal hematopoiesis (CH), a common state in cancer patients that is associated with a heightened risk of leukemia development. Owing to technical and sample size limitations, most CH studies have characterized gene mutations or mosaic chromosomal alterations (mCAs) individually. Here we leverage peripheral blood sequencing data from 32,442 cancer patients to jointly characterize gene mutations (n = 14,789) and mCAs (n = 383) in CH. Recurrent composite genotypes resembling known genetic interactions in leukemia genomes underlie 23% of all detected autosomal alterations, indicating that these selection mechanisms are operative early in clonal evolution. CH with composite genotypes defines a patient group at high risk of leukemia progression (3-year cumulative incidence 14.6%, CI: 7-22%). Multivariable analysis identifies mCA as an independent risk factor for leukemia development (HR = 14, 95% CI: 6-33, P < 0.001). Our results suggest that mCA should be considered in conjunction with gene mutations in the surveillance of patients at risk of hematologic neoplasms.
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http://dx.doi.org/10.1038/s41467-020-20565-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7804935PMC
January 2021

A pilot randomized controlled trial of a tailored smoking cessation program for people living with HIV in the Washington, D.C. metropolitan area.

BMC Res Notes 2021 Jan 6;14(1). Epub 2021 Jan 6.

Department of Environmental and Radiological Health Sciences, College of Veterinary Medicine & Biomedical Sciences, Fort Collins, CO, USA.

Objective: Morbidity and mortality from smoking-related diseases among people living with HIV (PLWH) in the U.S. surpasses that due to HIV itself. Conventional smoking cessation treatments have not demonstrated strong efficacy among PLWH. We conducted a pilot randomized controlled trial (RCT) to evaluate a tailored smoking cessation intervention based on the minority stress model. We compared standard of care counseling (SOC) to a tailored intervention (TI) including one face-to-face counseling session incorporating cognitive behavioral therapy to build resilience, and 30 days of 2-way text messaging.

Results: The primary outcome was smoking cessation. Secondary outcomes included cigarettes per day (CPD), exhaled carbon monoxide (CO), and cessation self-efficacy. A total of 25 participants were enrolled (TI:11, SOC:14), and 2 were lost to follow-up. There were no significant differences in quit rates between study groups. However, there was a significantly greater decrease in CPD in the TI versus SOC (13.5 vs. 0.0, p-value:0.036). Additionally, self-efficacy increased in both groups (TI p-value:0.012, SOC p-value:0.049) and CO decreased in both groups (TI p-value: < 0.001, SOC p-value:0.049). This intervention shows promise to support smoking cessation among PLWH. A larger study is needed to fully evaluate the efficacy of this approach.

Clinical Trial: Trial Registration: Retrospectively registered (10/20/2020) NCT04594109.
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http://dx.doi.org/10.1186/s13104-020-05417-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7789216PMC
January 2021

Lung Cancer Screening Knowledge, Perceptions, and Decision Making Among African Americans in Detroit, Michigan.

Am J Prev Med 2021 01;60(1):e1-e8

Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, Michigan. Electronic address:

Introduction: Previously, a web-based, patient-facing decision aid for lung cancer screening, shouldiscreen.com, was developed and evaluated. An initial evaluation was completed before the Medicare coverage decision and recruited a nondiverse sample of mostly former smokers, limiting the understanding of the potential effectiveness of the tool among diverse populations. This study evaluates shouldiscreen.com among African Americans in Metro Detroit.

Methods: Using insights obtained from participatory workshops in this population, content changes to shouldiscreen.com were implemented, and this modified version was evaluated with a before-after study. Measures included knowledge of lung cancer screening, decisional conflict, and concordance between individual preference and screening eligibility. Surveys occurred between April and July 2018. Participants were contacted 6 months after the survey to assess subsequent screening behaviors. Analysis took place in 2019.

Results: Data were collected from 74 participants aged 45-77 years, who were current/former smokers with no history of lung cancer. The average knowledge score increased by 25% from 5.7 (SD=1.94) before to 7.1 (SD=2.30) after (out of 13 points). Decisional conflict was halved between before and after. Concordance between individual preference and eligibility for screening increased from 22% (SD=41) to 35% (SD=47). Half of the participants felt uncomfortable answering surveys electronically and requested paper versions.

Conclusions: The use of the tool led to small improvements in lung cancer screening knowledge and increased concordance with current recommendations. Additional design modifications and modes of information delivery of these decision aids should be considered to increase their efficacy in helping populations with lower educational attainment and computer literacy.
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http://dx.doi.org/10.1016/j.amepre.2020.07.004DOI Listing
January 2021

Clonal hematopoiesis is associated with risk of severe Covid-19.

medRxiv 2020 Nov 27. Epub 2020 Nov 27.

Acquired somatic mutations in hematopoietic stem and progenitor cells (clonal hematopoiesis or CH) are associated with advanced age, increased risk of cardiovascular and malignant diseases, and decreased overall survival. These adverse sequelae may be mediated by altered inflammatory profiles observed in patients with CH. A pro-inflammatory immunologic profile is also associated with worse outcomes of certain infections, including SARS-CoV-2 and its associated disease Covid-19. Whether CH predisposes to severe Covid-19 or other infections is unknown. Among 515 individuals with Covid-19 from Memorial Sloan Kettering (MSK) and the Korean Clonal Hematopoiesis (KoCH) consortia, we found that CH was associated with severe Covid-19 outcomes (OR=1.9, 95%=1.2-2.9, p=0.01). We further explored the relationship between CH and risk of other infections in 14,211 solid tumor patients at MSK. CH was significantly associated with risk of (HR=2.0, 95% CI: 1.2-3.3, p=6×10 ) and infections (HR=1.5, 95% CI=1.1-2.1, p=5×10 ). These findings suggest a relationship between CH and risk of severe infections that warrants further investigation.
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http://dx.doi.org/10.1101/2020.11.25.20233163DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7709186PMC
November 2020

Transient expansion of TP53 mutated clones in polycythemia vera patients treated with idasanutlin.

Blood Adv 2020 11;4(22):5735-5744

Division of Hematology/Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY.

Activation of the P53 pathway through inhibition of MDM2 using nutlins has shown clinical promise in the treatment of solid tumors and hematologic malignancies. There is concern, however, that nutlin therapy might stimulate the emergence or expansion of TP53-mutated subclones. We recently published the results of a phase 1 trial of idasanutlin in patients with polycythemia vera (PV) that revealed tolerability and clinical activity. Here, we present data indicating that idasanutlin therapy is associated with expansion of TP53 mutant subclones. End-of-study sequencing of patients found that 5 patients in this trial harbored 12 TP53 mutations; however, only 1 patient had been previously identified as having a TP53 mutation at baseline. To identify the origin of these mutations, further analysis of raw sequencing data of baseline samples was performed and revealed that a subset of these mutations was present at baseline and expanded during treatment with idasanutlin. Follow-up samples were obtained from 4 of 5 patients in this cohort, and we observed that after cessation of idasanutlin, the variant allele frequency (VAF) of 8 of 9 TP53 mutations decreased. Furthermore, disease progression to myelofibrosis or myeloproliferative neoplasm blast phase was not observed in any of these patients after 19- to 32-month observation. These data suggest that idasanutlin treatment may promote transient TP53 mutant clonal expansion. A larger study geared toward high-resolution detection of low VAF mutations is required to explore whether patients acquire de novo TP53 mutations after idasanutlin therapy.
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http://dx.doi.org/10.1182/bloodadvances.2020002379DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7686898PMC
November 2020

Progress Toward Regional Measles Elimination - Worldwide, 2000-2019.

MMWR Morb Mortal Wkly Rep 2020 Nov 13;69(45):1700-1705. Epub 2020 Nov 13.

In 2010, the World Health Assembly (WHA) set the following three milestones for measles control to be achieved by 2015: 1) increase routine coverage with the first dose of measles-containing vaccine (MCV1) among children aged 1 year to ≥90% at the national level and to ≥80% in every district, 2) reduce global annual measles incidence to <5 cases per 1 million population, and 3) reduce global measles mortality by 95% from the 2000 estimate* (1). In 2012, WHA endorsed the Global Vaccine Action Plan, with the objective of eliminating measles in five of the six World Health Organization (WHO) regions by 2020. This report describes progress toward WHA milestones and regional measles elimination during 2000-2019 and updates a previous report (2). During 2000-2010, estimated MCV1 coverage increased globally from 72% to 84% but has since plateaued at 84%-85%. All countries conducted measles surveillance; however, approximately half did not achieve the sensitivity indicator target of two or more discarded measles and rubella cases per 100,000 population. Annual reported measles incidence decreased 88%, from 145 to 18 cases per 1 million population during 2000-2016; the lowest incidence occurred in 2016, but by 2019 incidence had risen to 120 cases per 1 million population. During 2000-2019, the annual number of estimated measles deaths decreased 62%, from 539,000 to 207,500; an estimated 25.5 million measles deaths were averted. To drive progress toward the regional measles elimination targets, additional strategies are needed to help countries reach all children with 2 doses of measles-containing vaccine, identify and close immunity gaps, and improve surveillance.
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http://dx.doi.org/10.15585/mmwr.mm6945a6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7660667PMC
November 2020

Medical student interpreter training schemes: an aid in post-COVID primary care?

Educ Prim Care 2021 Jul 6;32(4):249. Epub 2020 Nov 6.

University of Manchester, Manchester, UK,

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http://dx.doi.org/10.1080/14739879.2020.1845105DOI Listing
July 2021
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